Multi-modal entry for electronic clinical documentation

ABSTRACT

Methods, computer-readable media, and systems for populating an electronic clinical document capable of receiving multiple types of data are provided. In one embodiment, dictation audio input is embedded directly into one or more sections of an electronic clinical document along with other data types, such as structured user input, free-text input, or system-generated input. An electronic clinical document having embedded dictation audio and other data types can receive transcribed text corresponding to the embedded dictation audio.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of and claims the benefit of U.S.application Ser. No. 11/677,945, filed Feb. 22, 2007, entitled“Multi-Modal Entry for Electronic Clinical Documentation,” which claimsthe benefit of Provisional Application Ser. No. 60/886,448, filed Jan.24, 2007, and entitled “Multi-Modal Entry For Electronic ClinicalDocumentation,” both of which are hereby incorporated herein byreference.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

Not applicable.

BACKGROUND OF THE INVENTION

In recent years, healthcare service providers have been making thetransition from manual paper-based medical records to an electronicformat. Commercially available computer software, such as PowerChart®,PowerChart Office®, and other Cerner Millennium® applications marketedby Cerner Corporation of Kansas City, Mo. have advanced the state of theart well beyond the conventional manual approach. Electronic-basedrecords substantially increase the efficiency of healthcare providersand institutions. Electronic medical records also substantially reducerisks associated with high volumes of patient data and potentialliabilities arising out of clerical errors or misinformation. Theelectronic format enhances communication between various providers andwithin institutions. As electronic clinical documentation continues tobecome increasingly prevalent, the variety of applications, electronicforms, electronic charts, and user interfaces, as well as thecorresponding versatility of this format, continue to expand.

Dictation is commonly used by physicians and other healthcare providersto memorialize relevant information associated with patientinteractions. For example, a physician may recite a summary of symptomspresented by a particular patient as well as the physician's probablediagnosis, intended plan of treatment, and any necessary follow-upsteps. Dictation is often performed using tape recorders or othermechanical audio recording devices, and must be labeled and sent to atranscriptionist. Dictation cassettes can be mislabeled or lost, and arenot an efficient means of preserving audio data that is to accompanymedical records. Digital dictation devices are becoming more common, buteven with this new medium, digital dictation files still must beimported, attached, or otherwise appended to existing records. Similarproblems can arise with misidentification and mishandling of theseunassociated electronic audio files within vast medical informationsystems.

In addition, many currently available forms of electronic clinicaldocumentation are limited in their ability to combine multiple modes ofdata entry. For example, conventional electronic clinical forms do notallow a user to simultaneously import system-generated text, embed audiodata, receive free-text, and receive structured input; nor doconventional forms allow a user to enter these multiple modes of data atmultiple locations within an electronic clinical document. Some types ofelectronic medical documentation available today allow a user to merelyattach an audio file to the documentation. This form of documentation isinadequate, however, as attachments to electronic medical records sufferfrom various problems. For example, transcriptionists tasked withtranscribing the audio file generally do not have the benefit of seeingand understanding the context of the audio file within the electronicclinical document. As a result, the accuracy of the resultingtranscription is mediocre, at best. Further, a physician or otherprovider who has recorded audio relevant to the documentation typicallydoes not have access to the audio file once it is sent to betranscribed. As such, if the physician desires to review, edit or add tothe dictated information, the physician must wait until the transcribedaudio file is returned, which is inefficient and frustrating.

SUMMARY

Embodiments of the present invention relate to methods for populating anelectronic clinical document. In one embodiment, an electronic clinicaldocument capable of receiving multiple types of data, includingdictation audio input, structured user input, free-text input, andsystem-generated input is provided. Into the electronic clinicaldocument is subsequently received dictation audio input and at least oneof structured user input, free-text input, and system-generated input.In one embodiment, the electronic clinical document includes a pluralityof sections. Accordingly, the dictation audio input and the at least oneof structured user input, free-text input, and system-generated inputmay be received into one of the plurality of sections. Additionally, ifdesired, the dictation audio input may be received into at least two ofthe plurality of sections.

Embodiments of the present invention also relate to one or morecomputer-readable media having computer-executable instructions embodiedthereon for performing a method in a computerized healthcare system forpopulating an electronic clinical document having a plurality ofsections. In one embodiment, the method includes providing an electronicclinical document having a plurality of sections, at least one of theplurality of sections being capable of receiving input of multiple datatypes, receiving dictation audio input into at least two of theplurality of sections, embedding the dictation audio input into each ofthe at least two sections, and presenting graphical representationsindicative of the embedded dictation audio input in association witheach of the at least two sections.

In other embodiments, the present invention relates to computer systemsfor presenting an electronic clinical document. In one embodiment, thesystem comprises a data store operative to store an electronic clinicaldocument capable of receiving dictation audio input, structured userinput, free-text input, and system-generated input, one or morereceiving components operative to receive free-text input, structureduser input, system-generated input, and dictation audio input, anembedding component operative to embed transcribed text associated withdictation audio input, and a user interface component operative topresent a graphical representation of embedded dictation audio inputrelevant to a patient with whom the electronic clinical document isassociated and to present at least one of free-text input, structureduser input, and system-generated input on a common user interface.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

The present invention is described in detail below with reference to theattached drawing figures, wherein:

FIG. 1 is a block diagram of an exemplary computing system suitable foruse in implementing embodiments of the present invention;

FIG. 2 is a flow diagram showing an exemplary method for populating anelectronic clinical document with multiple types of data, in accordancewith an embodiment of the present invention;

FIG. 3 is a flow diagram showing an exemplary method for receivingtranscribed text into an electronic clinical document having embeddeddictation audio input associated therewith, in accordance with anembodiment of the present invention;

FIG. 4 is an exemplary screen display showing an electronic clinicaldocument interface for receiving and presenting multiple types of datainput, in accordance with an embodiment of the present invention;

FIG. 5 is an exemplary screen display of an electronic clinical documentfor receiving and embedding dictation audio input, in accordance with anembodiment of the present invention;

FIG. 6 is an exemplary screen display of an electronic clinical documenthaving a pop-up window indicative of an associated recording component,in accordance with an embodiment of the present invention;

FIG. 7 is an exemplary screen display of an electronic clinical documentwith a graphical representation indicative of embedded dictation audioinput, in accordance with an embodiment of the present invention;

FIG. 8 is an exemplary screen display of an electronic clinical documentwith a transcription input window for receiving transcribed textassociated with dictation audio input, in accordance with an embodimentof the present invention;

FIG. 9 is an exemplary screen display of an electronic clinical documentshowing transcribed text associated with dictation audio input that hasbeen entered into a section of the document into which the dictationaudio input was embedded, in accordance with an embodiment of thepresent invention;

FIG. 10 is an exemplary screen display for receiving transcribed textassociated with dictation audio input into an electronic clinicaldocument, in accordance with an embodiment of the present invention; and

FIG. 11 is an exemplary screen display of an electronic clinicaldocument showing multiple instances of embedded dictation audio input,in accordance with an embodiment of the present invention.

DETAILED DESCRIPTION

The subject matter of the present invention is described withspecificity herein to meet statutory requirements. However, thedescription itself is not intended to limit the scope of this patent.Rather, the inventors have contemplated that the claimed subject mattermight also be embodied in other ways, to include different steps orcombinations of steps similar to the ones described in this document, inconjunction with other present or future technologies. Moreover,although the terms “step” and/or “block” may be used herein to connotedifferent components of methods employed, the terms should not beinterpreted as implying any particular order among or between varioussteps herein disclosed unless and except when the order of individualsteps is explicitly described.

Embodiments of the present invention provide computerized methods,computer-readable media, and systems for populating and presenting anelectronic clinical document capable of receiving multiple types ofinput, including dictation audio input, structured user input, free-textinput, and system-generated input. An exemplary operating environment isdescribed below, though one of ordinary skill in the art will appreciatethat other suitable operating environments may be used.

Referring to the drawings in general, and initially to FIG. 1 inparticular, an exemplary computing system environment, for instance, amedical information computing system, on which the present invention maybe implemented is illustrated and designated generally as referencenumeral 20. It will be understood and appreciated by those of ordinaryskill in the art that the illustrated medical information computingsystem environment 20 is merely an example of one suitable computingenvironment and is not intended to suggest any limitation as to thescope of use or functionality of the invention. Neither should themedical information computing system environment 20 be interpreted ashaving any dependency or requirement relating to any single component orcombination of components illustrated therein.

The present invention may be operational with numerous other generalpurpose or special purpose computing system environments orconfigurations. Examples of well-known computing systems, environments,and/or configurations that may be suitable for use with the presentinvention include, by way of example only, personal computers, servercomputers, hand-held or laptop devices, multiprocessor systems,microprocessor-based systems, set top boxes, programmable consumerelectronics, network PCs, minicomputers, mainframe computers,distributed computing environments that include any of theabove-mentioned systems or devices, and the like.

The present invention may be described in the general context ofcomputer-executable instructions, such as program modules, beingexecuted by a computer. Generally, program modules include, but are notlimited to, routines, programs, objects, components, and data structuresthat perform particular tasks or implement particular abstract datatypes. The present invention may also be practiced in distributedcomputing environments where tasks are performed by remote processingdevices that are linked through a communications network. In adistributed computing environment, program modules may be located inlocal and/or remote computer storage media including, by way of exampleonly, memory storage devices.

With continued reference to FIG. 1, the exemplary medical informationcomputing system environment 20 includes a general purpose computingdevice in the form of a control server 22. Components of the controlserver 22 may include, without limitation, a processing unit, internalsystem memory, and a suitable system bus for coupling various systemcomponents, including database cluster 24, with the control server 22.The system bus may be any of several types of bus structures, includinga memory bus or memory controller, a peripheral bus, and a local bus,using any of a variety of bus architectures. By way of example, and notlimitation, such architectures include Industry Standard Architecture(ISA) bus, Micro Channel Architecture (MCA) bus, Enhanced ISA (EISA)bus, Video Electronic Standards Association (VESA) local bus, andPeripheral Component Interconnect (PCI) bus, also known as Mezzaninebus.

The control server 22 typically includes therein, or has access to, avariety of computer readable media, for instance, database cluster 24.Computer readable media can be any available media that may be accessedby control server 22, and includes volatile and nonvolatile media, aswell as removable and nonremovable media. By way of example, and notlimitation, computer readable media may include computer storage mediaand communication media. Computer storage media may include, withoutlimitation, volatile and nonvolatile media, as well as removable andnonremovable media implemented in any method or technology for storageof information, such as computer readable instructions, data structures,program modules, or other data. In this regard, computer storage mediamay include, but is not limited to, RAM, ROM, EEPROM, flash memory orother memory technology, CD-ROM, digital versatile disks (DVDs) or otheroptical disk storage, magnetic cassettes, magnetic tape, magnetic diskstorage or other magnetic storage device, or any other medium which canbe used to store the desired information and which may be accessed bycontrol server 22. Communication media typically embodies computerreadable instructions, data structures, program modules, or other datain a modulated data signal, such as a carrier wave or other transportmechanism, and may include any information delivery media. As usedherein, the term “modulated data signal” refers to a signal that has oneor more of its characteristics set or changed in such a manner as toencode information in the signal. By way of example, and not limitation,communication media includes wired media such as a wired network ordirect-wired connection, and wireless media such as acoustic, RF,infrared, and other wireless media. Combinations of any of the abovealso may be included within the scope of computer readable media.

The computer storage media discussed above and illustrated in FIG. 1,including database cluster 24, provide storage of computer readableinstructions, data structures, program modules, and other data forcontrol server 22. For example, the database cluster 24 can containelectronic clinical documents capable of receiving multiple types ofinput, including dictation audio input, structured user input, free-textinput, and system-generated input. Database cluster 24 can containelectronic medical records for various patients. Data from these recordscan be used by the system to generate system-generated input to bepopulated into sections of electronic clinical documents. For example, apatient's vital signs or portions of a patient's medical history, whichmay have been recorded or stored elsewhere in the system, may bepopulated by the system into an electronic note documenting a particularpatient encounter. Further, forms for supporting structured user inputmay also be stored in database cluster 24, and may be customized by aparticular health care provider or institution. And, electronic clinicaldocuments that have been populated with various forms of input can bestored in database cluster 24.

The control server 22 may operate in a computer network 26 using logicalconnections to one or more remote computers 28. Remote computers 28 maybe located at a variety of locations in a medical environment, forexample, but not limited to, clinical laboratories, hospitals and otherinpatient settings, ambulatory settings, medical billing and financialoffices, hospital administration settings, home health careenvironments, and clinicians' offices. Clinicians may include, but arenot limited to, a treating physician or physicians, specialists such assurgeons, radiologists and cardiologists, emergency medical technicians,physicians' assistants, nurse practitioners, nurses, nurses' aides,pharmacists, dieticians, microbiologists, and the like. Remote computers28 may also be physically located in non-traditional medical careenvironments so that the entire health care community may be capable ofintegration on the network. Remote computers 28 may be personalcomputers, servers, routers, network PCs, peer devices, other commonnetwork nodes, or the like, and may include some or all of the elementsdescribed above in relation to the control server 22.

Exemplary computer networks 26 may include, without limitation, localarea networks (LANs) and/or wide area networks (WANs). Such networkingenvironments are commonplace in offices, enterprise-wide computernetworks, intranets, and the Internet. When utilized in a WAN networkingenvironment, the control server 22 may include a modem or other meansfor establishing communications over the WAN, such as the Internet. In anetworked environment, program modules or portions thereof may be storedin the control server 22, in the database cluster 24, or on any of theremote computers 28. For example, and not by way of limitation, variousapplication programs may reside on the memory associated with any one orall of the remote computers 28. Computer network 26 can be coupled to aremote computer 28 for purposes of allowing a transcriptionist to accesselectronic clinical documents stored on database cluster 24. It will beappreciated by those of ordinary skill in the art that the networkconnections shown are exemplary and other means of establishing acommunications link between the computers (e.g., control server 22 andremote computers 28) may be utilized.

In operation, a user may enter commands and information into the controlserver 22 or convey the commands and information to the control server22 via one or more of the remote computers 28 through input devices,such as a keyboard, a pointing device (commonly referred to as a mouse),a trackball, or a touch pad. For example, a keyboard and mouse can beused to input free-text data, structured form data, or to inputuser-driven-populated data (e.g., such as by selecting categories ofdata to be populated by the system) to be received by the control server22 or by one or more of the remote computers 28. Other input devices mayinclude, without limitation, microphones, satellite dishes, scanners, orthe like.

Any type of microphone or other device capable of receiving audio inputmay be used to receive dictation audio input to be embedded intoelectronic clinical documents. Additionally, dictation audio input maybe received by an external audio recording source and then imported intoa remote computer 28 or into the control server 22. For example, aphysician or other health care provider can dictate using a digitaldictation device and then import the audio into a remote computer 28 orthe control server 22. The imported dictation audio input can then beembedded into an electronic clinical document, as more fully describedbelow.

The control server 22 and/or remote computers 28 can be coupled to acomputer monitor or other graphical display device capable of conveyinga user interface, such as the exemplary user interfaces discussed belowwith reference to FIGS. 4-11. The user interface can display free text,structured form data, system-generated data (including auto-populateddata and user-driven populated data), as well as other graphical-basedrepresentations of data. The control server 22 and/or remote computers28 may include other peripheral output devices, such as speakers and aprinter. Speakers, for example, can allow a health care provider,transcriptionist, or other appropriate individual to play back dictationaudio input that has been embedded into an electronic clinical document.

Although many other internal components of the control server 22 and theremote computers 28 are not shown, those of ordinary skill in the artwill appreciate that such components and their interconnection are wellknown. Accordingly, additional details concerning the internalconstruction of the control server 22 and the remote computers 28 arenot further disclosed herein.

Although methods and systems of embodiments of the present invention aredescribed as being implemented in a WINDOWS operating system, operatingin conjunction with an Internet-based system, one of ordinary skill inthe art will recognize that the described methods and systems can beimplemented in any system supporting the receipt and processing ofhealthcare orders and related information. As contemplated by thelanguage above, the methods and systems of embodiments of the presentinvention may also be implemented on a stand-alone desktop, personalcomputer, or any other computing device used in a healthcare environmentor any of a number of other locations.

As mentioned above, embodiments of the present invention providecomputerized methods, computer-readable media, and systems forpopulating and presenting an electronic clinical document capable ofreceiving multiple types of input, including dictation audio input,structured user input, free-text input, and system-generated input. Forsimplicity, the particular user will often be referred to as aclinician. However, it will be understood that the particular user maybe any healthcare professional, physician, or other provider, asdescribed above.

With reference to FIG. 2, an exemplary flow diagram representative of amethod for populating an electronic clinical document using multipletypes of data entry in accordance with an embodiment of the presentinvention is shown and referenced generally by reference numeral 200.Method 200 may be implemented using the above-described exemplarycomputing system environment (FIG. 1) and, by way of example only, maybe utilized by a clinician to populate an electronic clinical document(e.g., an electronic medical record) associated with a patient. (Theterms “individual”, “person”, and “patient” are used interchangeablyherein and are not meant to limit the nature of the referencedindividual in any way. Rather, the methods and systems described hereinare equally applicable in, for instance, a veterinary setting. Further,use herein of the term “patient” is not meant to imply any particularrelationship between the individual in question and those populating anelectronic clinical document associated with the individual.)

Initially, as shown at block 202, an electronic clinical documentcapable of receiving data entry through a plurality of modes, including,but not limited to, dictation audio input, structured user input,free-text input, and system-generated input is provided. The electronicclinical document can be provided via any type of graphical display,such as a computer monitor or any other type of graphical presentationapparatus, such as for example, an LCD screen, a laptop display, or ahandheld PDA device. An electronic clinical document can be any type ofelectronic medical documentation relevant to a particular patient andcan be part of an electronic healthcare information technology system.An electronic clinical document can also be a clinical event documentrelating to a particular clinical event for a patient, including, by wayof example only, a patient visit or encounter. By way of example and notlimitation, electronic clinical documents may be clinical notes,summaries, reports, analyses, or other types of electronic medicaldocumentation relevant to a particular patient's condition and/ortreatment. Electronic clinical documents contain various types ofinformation relevant to the condition and/or treatment of a particularpatient and can include information relating to, for example, patientidentification information, physical examinations, vital signs, pastmedical histories, surgical histories, family histories, histories ofpresent illnesses, current and past medications, allergies, symptoms,past orders, completed orders, pending orders, tasks, lab results, othertest results, patient encounters and/or visits, immunizations, physiciancomments, nurse comments, other caretaker comments, and a host of otherrelevant clinical information. Electronic clinical documents may bestored within an overall electronic medical chart or electronic medicalrecord associated with a patient.

The format for electronic clinical documents may be customized by theuser and/or may be established by a particular healthcare institution,such as by using a profile stored in a database, such as databasecluster 24, or by using a locally stored profile on a remote computer(e.g., remote computer 28 of FIG. 1).

“Dictation audio input”, as the term is utilized herein, refers to audiodata (for example, voice data recorded from a person's audible voice)that is recorded for the purpose of creating an audio record ofinformation that is to be later transcribed or automatically convertedinto text and associated with the electronic clinical document.Clinicians, for example, frequently dictate notes and other reports tomemorialize patient visits, diagnoses, and intended treatment plans.Dictation is used as a way to quickly capture the clinician'sobservations and recommendations in a format that can later be convertedto text and entered into pertinent sections of electronic medicalrecords for particular patients. In embodiments of the presentinvention, dictation audio input is stored in an electronic format. Anyelectronic audio format can be used, including, by way of example andnot limitation, WAV files, MP3 files, and the like. Compressed oruncompressed formats can be used and are contemplated as being withinthe scope of embodiments of the present invention. In embodiments,dictation audio input can be recorded in real time by a clinician user,such as by using a PC microphone on a personal computer, and thenembedded directly into an electronic clinical document. In otherembodiments, dictation audio input can be stored in an electronic file,transferred to or imported into a system, and then embedded into anelectronic clinical document. Any and all such variations andcombinations thereof, are contemplated to be within the scope ofembodiments hereof.

The electronic clinical document is also capable of receiving structureduser input. For example, a clinical form or table which providespre-defined structure designed for receiving user input relevant toparticular aspects of a patient's condition and/or treatment may be usedin accordance with embodiments of the present invention. The particularstructure used to guide the user's input may be customized by a useraccording to the user's particular preferences (including particularfields frequently used by the user) or according to a profileestablished, e.g., by a particular healthcare institution andimplemented across an electronic medical record system. For example, aclinician may wish to have a form designed to capture user inputregarding a patient's ambulation during a patient visit. In thisexample, the clinician can select from a number of pre-defined optionscommonly used to describe and categorize issues and observationsassociated with the patient's appearance and movement. Any type ofspecific selection method can be used within the form designed forreceiving structured user input. For example, boxes with check marks,circles, graphical highlights, or other graphical indicators may be usedto visibly represent selections made within a particular clinical formor table.

Selections may be made using any input means, such as those describedabove in connection with the exemplary computing system of FIG. 1,including, for example, a keyboard, mouse, touch screen, touchpad, orother pointing device. In one embodiment, a single “click” with a mouseover a particular word or phrase, such as “with crutches”, receives apositive input (“yes”) associated with the field (“with crutches”) andgenerates a graphical circle around the field. In this instance, theuser has indicated that the patient was using crutches when the user metwith the patient. In this embodiment, a second click with the mouseclears the selection and removes the graphical circle. In otherembodiments, where appropriate, a negative input may be received with anadditional mouse click. Though ambulation is provided as one example ofa subject for which structured user input may be received, any type ofclinical information relevant to the patient may be received viastructured user input provided that a particular form or table havingpre-defined selection parameters exists that is capable of capturing theinformation.

The electronic clinical document is further capable of receivingfree-text input. Free-text input can be received by a user utilizing akeyboard, for example, to enter textual characters into a text field,box, region, or other section within the electronic clinical document.Free-text input is not constrained in the way that structured user inputis constrained by pre-defined selection parameters. Any alpha-numericcharacters or symbols may be entered as free-text. Free-text input mayalso be imported into the clinical document, such as by being “copiedand pasted” from an e-mail or word processing document. Free-text inputmay be entered using any text-entry method, such as that used by commonword-processing software. Free-text input may be used by a user to entera brief summary of a patient visit or to enter a brief synopsis of apatient's medical history, for example. Any type of clinical informationrelevant to the patient may be entered into any section of theelectronic clinical document using free-text input.

The electronic clinical document is further capable of receivingsystem-generated input. System-generated input may be data that isauto-populated by the computer system automatically retrievinginformation relevant to the patient that is available from otherportions of the patient's electronic medical record, from otherlocations within the system, or from associated systems. For example, aparticular user's or institution's profile may indicate that all patientidentification information, vital signs, and all current medicationsprescribed to the patient that are stored in the system are to bepopulated into each clinical document that is generated whenever aparticular user chooses to create a new electronic clinical document forthe patient. Auto-population saves the user time by obviating the needto manually enter data into the electronic clinical document when theinformation is already available.

System-generated input may also be input using user-driven population,i.e. when, upon a request from the user, data that already exists forthe patient is retrieved from other portions of the patient's record,from other locations within the system, or from associated systems, andinput into a particular section or sections of the electronic clinicaldocument. For example, user-driven-populated data may be input upon auser requesting that the patient's vital signs or current medications bepopulated into the particular electronic clinical document. In thiscase, the relevant data already exists within the patient's record,within the system, or within an associated system. The data is merelyretrieved from the other location and used to populate a particularsection or sections of the current electronic clinical document beinggenerated. This differs from auto-population in that the data is notautomatically populated into the document as a matter of course, butrather the user must request that the particular type of information bepopulated into the document. In embodiments of the present invention,either auto-populated data entry or user-driven-populated data entry, orany combination thereof, may be used as system-generated input.

Once the electronic clinical document capable of receiving the multiplemodes of data entry has been provided, such as by way of a graphicaluser interface, multiple types of data input may be received. In theillustrated embodiment, dictation audio input is received into theelectronic clinical document, as indicated at block 204, in addition toat least one of structured user input, free-text input, andsystem-generated input, as indicated at block 206. Any appropriate audiocapture method can be used to capture the dictation audio input, such asan audio input device that is a part of the exemplary computing systemenvironment described above with reference to FIG. 1. For example, acomputer microphone (external or internal) may be used to capture thedictation audio spoken by a particular user. A graphical interface,which is more fully described below with reference to FIG. 6, can beused, for example, to allow the user to control the start and stop ofthe recording process. If a user is not satisfied with the particularrecording, the audio file can be deleted and re-recorded by the user.Once the user is satisfied with the particular recording, the user canchoose to save the dictation audio input, which is then embeddeddirectly into the electronic clinical document at the location where theuser selected to enter dictation audio input. A graphicalrepresentation, such as an icon, may be generated by the system anddisplayed at the particular location where the dictation audio input wasembedded. In embodiments, a dictation audio identifier is assigned tothe particular dictation audio input to identify it within the system,and that can be used by a pointer to serve as a reference between thedictation audio input and the document. The identifier associates therecorded dictation audio input with the particular patient, theparticular electronic clinical document, and the particular locationwithin the document. In one embodiment, the identifier is a multi-digitnumeral.

In addition to real-time audio capture, previously recorded audio filescan be embedded into sections of the electronic clinical document. Inembodiments of the present invention, multiple dictation audio inputscan be received at multiple locations within an electronic clinicaldocument, within a particular section of an electronic clinicaldocument, and can be moved and/or copied from one location to another.

Receipt of at least one of structured user input, free-text input, andsystem-generated input may be into the same section or sections as thedictation audio input received at step 204, or can be received into adifferent section of the electronic clinical document. Any section ofthe electronic clinical document can optionally receive any of the typesof input described, including dictation audio input, structured userinput, free-text input, and system-generated input. For example, in aphysical examination section of a clinical note being populated by aclinician for a patient, the clinician-user can enter dictation audioinput, free-text input, structured user input, and system generatedinput. Each section has the ability to receive multiple types of dataentry. Also, any order of data entry is possible using embodiments ofthe present invention. Additionally, auto-populated system-generatedinput may be entered automatically into the electronic clinical documentwhen the document is initially created or accessed by the user. Further,an electronic clinical document can receive data input, be stored in thesystem for later access or editing, and additional input (includinginput from any of the above-described modes of data entry) can beentered into the electronic clinical document.

With reference to FIG. 3, a detailed method 300 for receivingtranscribed text associated with dictation audio input into anelectronic clinical document having the dictation audio input embeddedtherein is represented by a flow diagram. After dictation audio inputhas been received into an electronic clinical document and embedded intoone or more sections of the document, the dictation audio input may betranscribed. The electronic clinical document may have received none,any, or all of the other types of data entry described above inconnection with FIG. 2, in addition to the dictation audio input.Initially, as indicated at block 302, the electronic clinical documenthaving the embedded dictation audio is transmitted to atranscriptionist. The electronic clinical document may be transmitted inany format. The electronic clinical document may be itself sent to thetranscriptionist or an electronic reference or link to the document maybe sent. For example, an e-mail to a transcriptionist may be generatedand sent once a clinician indicates that the document has dictationaudio input that is ready to be transcribed. In the alternative, atranscriptionist may simply be notified that the electronic clinicaldocument has new audio that is ready to be transcribed and be providedlimited access to the electronic clinical document on the system. Inembodiments of the present invention, the embedded dictation audio inputis the only portion of the document that the transcriptionist ispermitted to access.

As indicated at block 304, the electronic clinical document is presentedto the transcriptionist using a graphical user interface that “locks”the underlying data in the document with respect only to thetranscriptionist. In other words, the transcriptionist is allowed toview the data in the document, but cannot edit any of the existing data(i.e., the transcriptionist is not given “write access” to any of theexisting data). This ensures the integrity of the document, as createdby the user. Thus, the transcriptionist is given “read-only” access tothe existing data, but is allowed to enter transcribed text associatedwith the embedded dictation audio input into the electronic clinicaldocument. In an embodiment of the present invention, the underlying datain the electronic clinical document can be anonymized, such that actualpatient identification information is replaced with alternate “John Doe”information to preserve medical confidentiality and patient anonymity.

The transcriptionist can view the graphical representation of theembedded dictation audio indicating the location or section where thedictation audio was input into the document. This allows thetranscriptionist to see the context within which the dictation wasrecorded. For example, the transcriptionist can view other relevantinformation in the note to assist in transcribing the audio file. Also,the clinician or other user who populated the electronic clinicaldocument can still access the document, including the dictation audio,even after a link or other reference has been sent to thetranscriptionist. This feature allows the clinician to access thepatient's complete electronic clinical document should the clinicianhave a need for the information before the transcriptionist hastranscribed any embedded audio.

Subsequently, as indicated at block 306, a request is received to outputthe dictation audio. For example, the transcriptionist may double-clickon the graphical representation of the embedded dictation audio input toinitiate playback of the audio file. Then, as indicated at block 308,the stored dictation audio input is accessed and output. The audio filemay be output via any audio output means, such as those described abovewith reference to FIG. 1. For instance, computer speakers or headphonesmay be used to output the audio.

Subsequently, as indicated at block 310, transcribed text associatedwith the dictation audio input is received and stored in associationwith the electronic clinical document. The transcription input can bereceived in a transcription entry box, such as that described below.After the transcriptionist indicates that the entry is complete, such asby selecting a “done” or “save” selectable indicator, the transcribedtext is stored in the same location as the corresponding dictation audioinput. For example, if the clinician embedded dictation audio input intoa “physical examination” section of the electronic clinical document,then the transcribed text received corresponding to this dictation audioinput is received into the “physical examination” section of thedocument. In this embodiment, the embedded dictation audio input ispreserved to allow the clinician to listen to the recorded dictationaudio again, for example, if the clinician notices any potential errorsin the transcribed text. In this embodiment, the clinician mayoptionally edit the transcribed text as free text in order to make anycorrections or additions.

In another embodiment, the dictation audio input may be automaticallyconverted to transcribed text using voice recognition software. Variousvoice recognition techniques are known in the art and any can be used inconjunction with the present invention to allow real-time voice-to-textconversion. In the alternative, after a dictation audio file has beenrecorded and embedded, a voice-to-text conversion can be performed onthe completed file to convert it to text. Similar to the manualtranscription process discussed above, the embedded dictation audioinput and graphical representation are preserved to allow the user todouble-check the voice-to-text conversion.

Exemplary user interfaces for performing various embodiments of thepresent invention will now be discussed. These user interfaces areexemplary in nature and should not be treated as limiting. Withreference to FIG. 4, an exemplary user interface 400 is provided forpopulating an electronic clinical document 406 with multiple types ofdata entry, including dictation audio input. An electronic clinicaldocument can be a stand-alone electronic medical document or it can bepart of an electronic clinical record stored within an electronicmedical records system. In FIG. 4, for example, the electronic clinicaldocument 406 is a part of an electronic clinical record 402 for aparticular patient. In this case, an electronic clinical document isdisplayed for Ella Baronian, a 6-year old, female patient. Thedocumentation portion of the electronic clinical chart 402 can bedisplayed using the documentation tab 404. The electronic clinicaldocument 406 in this example is an office clinic note regarding EllaBaronian that is being populated by physician John Jones on May 23, 2006at 10:08 A.M.

In embodiments of the present invention, the electronic clinicaldocument 406 comprises a plurality of sections 408A-C. The plurality ofsections can be displayed on a common user interface, such as within asingle tab (e.g., documentation tab 404) or on a single-screen view. Ifthe electronic clinical document contains more information than can fitin the allotted screen area of a display device, then a scroll bar orother navigation buttons can be used to allow the user to navigate toadditional information within the tab. In embodiments, the sections408A-C can further comprise subsections, such as subsections 409A-B.These sections (and subsections) categorize clinical informationrelevant to the treatment of a particular patient. By way of example,and not limitation, these sections and subsections can includecategories such as history of present illness, health status, allergies,current medications, problem lists, past medical history, surgicalhistory, family history, social history, review of systems, physicalexamination, vital signs, general information, skin conditions,laboratory and test results, physician impression and plan, professionalservice, etc. Each of these sections (and subsections) may be capable ofreceiving multiple types of data entry, including dictation audio input,structured user input, free-text input, and system generated input. Inaddition, in an embodiment, multiple instances of each data type mayappear within one or more of these sections. Further, the subsectionscan be alternatively displayed or hidden using substructure displayregions, such as substructure display regions 422A-C. When any of thesubstructure display regions 422A-C is selected, subsections aredisplayed if not currently displayed and hidden if currently displayed.In this example, subsections 409A-B are revealed, but can be hidden by auser selecting substructure display region 422C, which is labeled “hidestructure.” Each of these subsections can receive dictation audio input,structured user input, free-text input, and system-generated input, inany combination or in any number of instances.

Further, in this embodiment, each of the electronic clinical documentsections 408A-B has a corresponding dictation selection region 420A-Boperative to receive requests to receive dictation audio input. Inembodiments, when dictation audio input is received, it is recorded andembedded directly into the electronic clinical document 406 andrepresented by a graphical representation 412, such as an icon,indicative of the embedded dictation audio input associated with theparticular section. In this example, dictation audio input has beenembedded into section 408C, labeled as “physical examination” and isrepresented by graphical representation 412. In this embodiment, thegraphical representation 412 includes an associated dictation identifierthat identifies the section, electronic clinical document, and thepatient. In this case, the ID number “211437” associates the embeddeddictation audio with the “physical examination” section, with thisparticular office clinic note created by Dr. John Jones on May 23, 2006,and with patient Ella Baronian.

In this example, user interface 400 also displays free-text input 410that has been input into section 408B of electronic clinical document406. As described above, any alpha-numeric text or other text typicallyused by common word-processing applications can be entered as free-textinput. In an embodiment, graphics may be embedded in the same mannerthat graphics are commonly embedded into word processing documents byconventional word processing applications. Though FIG. 4 displaysfree-text only in one section of the electronic clinical document, anyof the sections can receive free-text input, including multipleinstances of free-text input within an individual section.

In this example, the electronic clinical document 406 also displaysstructured user input 416 that has been entered into subsection 409B. Inthis case, the general subsection of the physical examination sectionhas received structured user input in an ambulation form with structureduser input selections 418A-B. Structured user input selection 418Aindicates that the patient's gait was “WNL” or within normal limits, andstructured user input selection 418B indicates that the patient was“well groomed.” Though electronic clinical document 406 displaysstructured user input within only one section, each section can containstructured user input, including multiple instances of it withinindividual sections. Further, structured user input 416 is merelyexemplary in nature and should not be considered limiting. As describedabove with reference to FIG. 3, structured user input can be entered byway of any pre-defined template, form, table, etc. having variouspre-defined selection options.

Further, the electronic clinical document 406 also displayssystem-generated input 414. System-generated input includes bothauto-populated input and user-driven-populated input, as described inmore detail above with reference to FIG. 2. In this example, theelectronic clinical document 406 has received system-generated input 414through auto-population. In this embodiment, the patient Ella Baronian'svital signs from a recent patient visit have been auto-populated intoDr. Jones' office clinic note. In this case, the system-generated inputreceived includes the patient's oral temperature, peripheral pulse rate,respiratory rate, systolic blood pressure, and diastolic blood pressure.In another embodiment, the user may indicate that he or she wishes topopulate an electronic clinical document with laboratory test results,such as by using a pull-down window. In this instance, laboratory testresults stored elsewhere in the system are populated into a desiredsection of the electronic clinical document via user-driven population.Any type of information relevant to the patient stored elsewhere withinthe patient's record or elsewhere on the system can be populated assystem-generated input into the electronic clinical document. By usingsystem-generated input (in either form), a user can conveniently avoidhaving to re-enter data that is already available elsewhere in thesystem, saving time and avoiding clerical mistakes.

FIGS. 5-9 provide exemplary screen displays of a sequence of screensthat can be used to receive dictation audio input and subsequentcorresponding transcribed text associated therewith into an electronicclinical document.

With reference to FIG. 5, an exemplary screen display 500 is shown whichpresents an electronic clinical document 504. The electronic clinicaldocument 504 comprises a plurality of sections 502A-B. Within sections502A-B are corresponding dictation selection regions 506A-B, which arecapable of receiving requests to receive dictation audio input to beembedded into the respective sections. Upon selection of dictationselection region 506A within section 502A, labeled as “history ofpresent illness,” a user interface 600 is displayed for receivingdictation audio input, as shown in FIG. 6. User interface 600 displays adictation pop-up window 602 operative to receive dictation audio input.Dictation pop-up window 602 comprises a recording status display 604 andrecording controls 606. This user interface is merely exemplary innature and should not be deemed limiting. The dictation pop-up window602 allows a user to start recording dictation audio input, pauserecording, re-play recorded dictation audio, and stop recording. Oncethe user selects to stop recording, the received dictation audio inputis embedded into the electronic clinical document 504 and represented bya graphical representation 702, as shown by exemplary user interface 700in FIG. 7. Graphical representation 702 appears in the same section 502Ain which the dictation selection region 506A was selected. In thisinstance, graphical representation 702 is an icon indicating thatdictation audio input has been received and embedded into the “historyof present illness” section (section 502A) of electronic clinicaldocument 504. This embodiment is merely exemplary in nature and shouldnot be deemed limiting.

With reference to FIG. 8, an exemplary screen display 800 is shown forreceiving transcribed text from a transcriptionist based on embeddeddictation audio input received into the electronic clinical document504. After a user has input dictation audio into an electronic clinicaldocument, it can be transmitted to a transcriptionist, as describedabove. It can be transmitted separately or it can be transmitted as partof the electronic clinical document, with the underlying layers of thedocument “locked”, as described above. In this embodiment, display 800shows the latter, with the embedded dictation audio in the context ofthe underlying “locked” layers of the electronic clinical document 504.Upon selection of the graphical representation 702, the associateddictation audio is output via any of the audio output means discussedabove. Also, in this embodiment, a transcribed text input window 802 isdisplayed for receiving transcribed text 804 from the transcriptionist.Once the transcription is complete, the transcriptionist can selectregion 806 to indicate completion. Upon selection of region 806, thetranscribed text is placed into the corresponding section where theassociated dictation audio input is embedded. FIG. 9 displays anexemplary screen 900 showing this text input as transcribed text 902within the corresponding section where the associated dictation audioinput is embedded.

With reference to FIG. 10, in another embodiment, an exemplary screendisplay 1000 can be used to receive transcribed text from atranscriptionist based on embedded dictation audio input. In thisembodiment, the transcribed text is received into a window 1002. Apreview window 1004 displays a preview of the preliminary reportcorresponding to an electronic clinical document.

With reference to FIG. 11, an exemplary screen display 1100 is shownwhich displays graphical representations 1102A-B corresponding toseparate dictation audio inputs that have been embedded into multiplesections of an electronic clinical document 1104. In accordance withembodiments of the present invention, multiple sections of electronicclinical documents can receive embedded dictation audio input, as wellas the other types of input discussed above.

The present invention has been described in relation to particularembodiments, which are intended in all respects to be illustrativerather than restrictive. Alternative embodiments will become apparent tothose of ordinary skill in the art to which the present inventionpertains without departing from its scope.

From the foregoing, it will be seen that this invention is one welladapted to attain all the ends and objects set forth above, togetherwith other advantages which are obvious and inherent to the system andmethod. It will be understood that certain features and sub-combinationsare of utility and may be employed without reference to other featuresand sub-combinations. This is contemplated by and within the scope ofthe claims.

1. A method in a computerized healthcare system for populating anelectronic clinical document, the method comprising: providing anelectronic clinical document for a particular patient, the electronicclinical document being capable of receiving dictation audio input,structured user input, free-text input, and system-generated input;receiving dictation audio input into the electronic clinical document,wherein the dictation audio input is audio data; receiving at least oneof structured user input, free-text input, and system-generated inputinto the electronic clinical document; embedding the dictation audioinput directly into the electronic clinical document; presentingrepresentations indicative of each of the embedded dictation audio inputin the electronic clinical document; and assigning a dictation audioidentifier to each of the representations, wherein the dictation audioidentifier associates the dictation audio input with the particularpatient, the electronic clinical document, and a location of thedictation audio input within the electronic clinical document.
 2. Themethod of claim 1, wherein the electronic clinical document comprises aplurality of sections.
 3. The method of claim 2, wherein the dictationaudio input and the at least one of structured user input, free-textinput, and system-generated input are received into one of the pluralityof sections of the electronic clinical document.
 4. The method of claim2, wherein the plurality of sections are displayed in a common userinterface.
 5. The method of claim 2, wherein the plurality of sectionsare displayed within a single tab.
 6. The method of claim 2, wherein theplurality of sections are displayed within a single-screen view.
 7. Themethod of claim 1, wherein the dictation audio input is received into atleast two of the plurality of sections of the electronic clinicaldocument.
 8. The method of claim 1, further comprising receiving atranscribed body of text associated with the dictation audio input. 9.The method of claim 8, further comprising receiving additional dictationaudio input into the transcribed body of text.
 10. One or more computerstorage media having computer executable instructions embodied thereonfor performing a method in a computerized healthcare system forpopulating an electronic clinical document having a plurality ofsections, the method comprising: providing an electronic clinicaldocument for a particular patient having a plurality of sections, atleast one of the plurality of sections being capable of receiving inputof multiple data types; receiving dictation audio input into at leasttwo of the plurality of sections, wherein the dictation audio input isaudio data; embedding the dictation audio input directly into each ofthe at least two of the plurality of sections; presentingrepresentations indicative of the embedded dictation audio input inassociation with each of the at least two of the plurality of sections;and associating the dictation audio input with the particular patient,the electronic clinical document, and locations of the dictation audioinput within the electronic clinical document.
 11. The computer storagemedia of claim 10, wherein the at least one of the plurality of sectionsthat is capable of receiving input of multiple data types is capable ofreceiving at least dictation audio input, structured user input,free-text input, and system-generated input.
 12. The computer storagemedia of claim 10, wherein the method further comprises receiving atleast one of structured user input, free-text input, andsystem-generated input into one of the at least two sections havingdictation audio input embedded therein.
 13. The computer storage mediaof claim 12, wherein the method further comprises presenting the atleast one of structured user input, free-text input, or system-generatedinput in association with the section into which it was received. 14.The computer storage media of claim 10, wherein the method furthercomprises receiving into one or more of the at least two of theplurality of sections, transcribed text associated with the dictationaudio input embedded therein.
 15. The computer storage media of claim14, wherein the method further comprises: presenting the transcribedtext within the at least one of the plurality of sections with which thedictation audio input associated with the transcribed text is embedded.16. The computer storage media of claim 10, wherein the plurality ofsections are provided in a common user interface.
 17. The computerstorage media of claim 10, wherein the plurality of sections areprovided in a single-screen view.
 18. The computer storage media ofclaim 10, wherein the plurality of sections are provided within a singletab.
 19. One or more computer storage media having computer executableinstructions embodied thereon for performing a method in a computerizedhealthcare system for populating an electronic clinical document havinga plurality of sections, the method comprising: providing an electronicclinical document for a particular patient, the electronic clinicaldocument having a plurality of sections, wherein at least one of thesections is capable of receiving dictation audio input, structured userinput, free-text input, and system-generated input, and wherein theplurality of sections are displayed within a single-screen view;receiving the dictation audio input into the electronic clinicaldocument, wherein the dictation audio input is audio data, and whereinwhile the dictation audio input is being received into the electronicclinical document, existing data in the electronic clinical document islocked so that read-only access is given to the existing data; receivingthe free-text input into the electronic clinical document; embedding thedictation audio input directly into each of the at least two of theplurality of sections; presenting representations indicative of theembedded dictation audio input in association with each of the at leasttwo of the plurality of sections; providing a dictation audio identifierfor each of the representations; and utilizing the dictation audioidentifier to associate the dictation audio input with the particularpatient, the electronic clinical document, and a location of thedictation audio input within the electronic clinical document.